JOHN P. SALVO JR, MD
KEVIN O’DONNELL, MD
Editor’s Note: John Salvo, a trusted colleague and Rothman Institute partner, has one of the busiest sports orthopedic practices in the Philadelphia area. He does many hip arthroscopies and keeps a keen eye out for medical and surgical traps. It seemed appropriate for John and his fellow Kevin to write this chapter.
Here’s the rest of the story.
—Paul Harvey, the famous conservative American ABC radio broadcaster.
AN ARCHETYPAL TRAP—HIP DYSPLASIA
Everyone looked up to Becky, a model student and captain of the cheerleading team in her senior year in high school. No one knew she was suffering, and now taking an occasional narcotic to fight off the growing pain in her right groin. Simple walking was becoming difficult, let alone jumping from a pyramid.
The pain started her junior year, a barely uncomfortable “popping” deep in her groin. She had joked with her cheerleading mates about the loudness of it since ninth grade. She thought little of the popping then. It was definitely not painful. So, this school year, she initially discounted the new slight ache. Then the ache began to travel deeper and into her buttock, and then got so bad, she stopped competing. The cause of the popping, she was told, was a simple tear in her labrum, some loose cartilage in her hip, and something called femoroacetabular impingement (FAI). It would all be addressed via a hip scope, by shaving off a bump of bone, “debriding” cartilage, and “releasing” her psoas muscle. She understood that the psoas muscle traveled intimately close to and in front of her hip, rubbing against it and causing the popping.
Becky did not do well, to say the least, after the arthroscopic surgery. At 4 months, she could no longer take even a few steps without severe pain. “My hip is coming out of joint,” she conveyed to everyone. Becky could not do simple tasks, let alone return to cheerleading. Frustrated, she and her family sought another opinion.
From plain X-rays done in the clinic, Becky’s problem became clear. She had, what the new hip surgeon announced, hip dysplasia, a more serious problem than simple impingement. A portion of her hip socket had never developed so she was prone to hip instability. The growth development problem was only “moderate,” but the combination of the reduction in bone, the loss of more of her labrum, and the surgical psoas detachment had created a new problem, called hip instability. That was why she walked with so severe a compensatory tilt. Her pelvis was shifting and altering the direction of forces in order to minimize the pain. She was told by the second hip surgeon that treatment might, fortunately, be relatively straightforward. At this point, she knew there was no guarantee. Becky underwent the second hip arthroscopy, at which time tissue was taken from her leg and a new labrum created. At the time, she also underwent “repair” of her hip capsule. Nothing could be done, she was told, about the psoas release.
Two days after surgery, Becky felt she had been “cured.” Her preoperative pain was no longer present. She stopped all her pain meds and felt normal. At 14 days, she discarded her crutches and walked without a limp. Becky did well for the next 4 years. As Paul Harvey used to say, here is the rest of the story.
She never did return to cheerleading or other vigorous activities. She graduated from nursing school and then became a certified nurse practitioner. Five years out from surgery, she developed similar pains and eventually underwent a periacetabular osteotomy operation. This procedure involved intentional fracture and reorientation of her hip socket. At the present time, 2 years after the third surgery, she has no pain whatsoever again. She is aware, though, that she may require total hip replacement in the not-too-distant future.
HIP ARTHROSCOPY REMAINS NEW
Unfortunately, Becky’s story is not unique. Whether or not her end result was inevitable is debatable. But, in a nutshell, she represents the sorts of potential ambushes that hip arthroscopists face every day. We must continually remind ourselves that we live still in the formative years of a new field.
The whole field developed in the late 1990s and early 2000s. Techniques have sprouted from simple removal of loose bodies, to labral debridement, and then to applying the discoveries of Ganz. No matter how experienced any of us are, we all remain on a learning curve. The curve is extremely steep initially and, at different points for each of us, becomes more gradual. There are numerous ledges on that curve where we may fall. The trick is to avoid as many of those ledges as possible. All within this field continue to experience traps prowling out there. (See Figure 24-1.)
Becky’s initial surgical team encountered at least 2 ambushes: Certainly, they missed the hip dysplasia, and the psoas release likely contributed to her hip instability. But who really knows if the latter is true? Perhaps, they shaved away too much bone or reduced a critical amount of intrinsic vacuum with the labral debridement. We shall never know exactly. Surely, 1, 2, or all of those 3 factors contributed to the arrival of hip stability in this preoperatively stable, yet already dysplastic, hip. By definition, a dysplastic hip teeters on instability. It does not take much to tip this type of hip into instability. Chapter 25 discusses developmental hip problems in much more depth.
What we shall go through here is a top 15 list of the traps in hip arthroscopy. More traps loom out there, ready to pounce on us “innocent” hip arthroscopists, athletic trainers, and other fitness experts. We can’t play innocent sheep much longer.
Figure 24-1.
A little dreaming is dangerous, the cure is not to dream less but to dream more, to dream all the time.
—Marcel Proust.
THE MINEFIELD
The Usual Femoroacetabular Impingement Work-Up
Okay, so we have made a lot of progress in hip arthroscopy. And we await more progress. As mentioned previously (see Chapters 1 and 2), one of the great things about medicine is empiricism. And, as stated before, one of the really bad things about medicine is empiricism. Empiricism brings a certain safety to physicians’ decision-making. But it also blinds us. By doing only what we have been taught, we can only extend the horizons of our eyes rather than put on new eyes. Remember our lead quote from Marcel Proust in Chapter 2.
Think about the new Marcel Proust quote listed above. The dreams and imaginations of Ganz, Byrd, Villar, and others are what put hip arthroscopy on the sports medicine map. Hip arthroscopy seems now well incorporated into training programs. But we have to ask ourselves, isn’t this too soon for hip arthroscopy to be thus so much incorporated? Many of us in the field have barely moved off the steep part of the learning curve. Isn’t it too soon for the work-up and treatment of FAI to become written into stone?
We physicians have a lot of pressure on us to provide cookbook medicine, black-and-white stuff that residents-intraining can follow and pass their boards and get credentialed. From a patient safety standpoint, routine may seem good. But is it good during the development of a new field? Routine may benefit some patients, but how many? Is it possible that routine stifles our imaginations, shuts down our dreams? Routine is certainly not good for all patients. It protects us in some ways, but does it also somehow close our eyes? Remember hip arthroscopy remains relatively new. How can we mandate things when we don’t yet know what to mandate? We must not close our eyes already. Keeping our eyes wide open will help us avoid the many traps out there.
The work-up and treatment of FAI may have already become too demarcated at this point. Let’s go through what has become routine. The usual initial work-up for FAI includes a series of plain radiographs, usually an “AP pelvis,” “AP and cross table lateral of the hip,” a “modified Dunn view,”1 and a “false profile view of the affected hip.”
Several radiographic measurements detect the presence of FAI and further classify the type of FAI (eg, cam, pincer, or a mixed lesion). Knowing the type of FAI helps us formulate the plan of surgical attack and to “stay out of trouble.” Typically, the measurements include the alpha-angle, lateral center edge angle, anterior center edge angle, and the sourcil angle. We should also look for coxa breva, coxa magna, coxa profunda, or protrusio acetabuli. Plus, we should also look for hip dysplasia or acetabular undercoverage. And, oh yes, we should look for arthritis. If the patient has “too much” arthritis, sometimes we should “stop right there.” Phew, that’s a lot to look for. We are only human. Ask yourself if it is possible for the hip arthroscopist to miss something?
Add to this insurance companies entering into the clinical arena and requiring certain hip angles for them to pay for surgery.
Here’s the rest of the story. Following the plain radiographs, we order MRIs and MR-arthrograms. We argue about using 3 vs 1.5 Tesla MRIs. We look for such things as chondral damage, stress fractures, or associated psoas and abductor muscle problems. We may get 3-dimensional CT scan reconstructions.2 We also may inject a local anesthetic or corticosteroid for diagnostic or therapeutic purposes. Algorithmic decisions often depend on response to injections, physical therapy, and even alternative therapies. Again, insurance companies now play big roles in our decision-making processes.
Let’s go on. Hip arthroscopists then focus on the type of FAI, precise location of the impingement, and degree of pathology. We decide what to do among the various available procedures and choose among ones we have been trained to do (eg, labral repairs, grafting, acetabuloplasty, femoroplasty, microfracture, psoas lengthening, abductor repair). Granted, the algorithm has been vetted with consistent good-to-excellent short- and mid-term outcomes, but sometimes we still need to think outside the box to allow our success to expand.
Keeping the Dream
Before careers of young hip arthroscopists even start, so much unproved, mandated information packs their brains. What about a good history and physical examination? Add perhaps some plain X-rays and maybe an MRI, and some savvy clinical judgment? How about talking to colleagues and find out if a specific clinical situation has ever been faced before and how it was handled? How does one value savvy and clinical experience? With today’s clinical care yielding so much to regulatory pressures, we are forced to follow algorithms and care maps. Fear replaces the desire to accumulate experience. Many patients, miserable with hip pain, remain out there, outside the guidelines and who can be corrected.
New hip arthroscopy fellowship–trained surgeons can’t help but follow suit, stick to their training, and make decisions based on what seems best, what has been done before, and whatever it takes to follow the mandated “guidelines.” With so much (yet so little) in our heads, of course, young hip arthroscopists shall follow guidelines to the hilt. The confidence of experience never arrives, at least in the right way. Success with several straightforward cases may generate cockiness, but that’s not the right confidence. They shall miss opportunities to cure patients because of growing fears of going outside of the guidelines. They shall miss subtleties in many individual patients. They won’t take a chance and cure the patient who does not fit the mandated guidelines. That said, it remains remarkable that we do as well as we do.
The traps come in many categories, not just patient selection, under- or overtreatment, or misdiagnosis and operative mishaps. Here are a few questions that provide the camouflage for ambush: What guidelines should be followed in deciding how much bone to remove? How should we treat articular cartilage damage? When should we employ microfracture or the use of intrinsic or extrinsic substances to help hip arthritis? Let’s face it, thus far, hip arthroscopy remains as much an art as a science.
“Thirty” has been suggested as the number of cases that a hip arthroscopist must do to become “proficient.”3 What about the patients who are those 30 cases? What about after that? The truth is that the whole world of hip arthroscopy is evolving. This world is fast-paced and a process of learning and improving. The exact number of cases is immaterial. Right now, we’ve got to keep our senses keen and deflect the noise of regulatory mandates. Right now, we learn from every case we do. Experience has no competitor.
A dream doesn’t become reality through magic; it takes sweat, determination, hard work, and experience.
—Colin Powell, American statesman and retired 4-star US Army general.
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